Search

Coronavirus disease (COVID-19) has profoundly impacted residency training and education. To date, there has not been any broad assessment of urological surgery residency changes and concerns during the COVID-19 pandemic.The Society of Academic Urologists distributed a questionnaire to urology residency program directors on March 30, 2020 exploring residency program changes related to the COVID-19 pandemic. Descriptive statistics are presented. A qualitative analysis of free response questions was undertaken. A post hoc analysis of differences related to local COVID-19 incidence is described.The survey was distributed to 144 residency programs with 65 responses for a 45% response rate. Reserve staffing had started in 80% of programs. Patient contact time had decreased significantly from 4.7 to 2.1 days per week (p0.001). Redeployment was reported by 26% of programs. Sixty percent of programs reported concern that residents will not meet case minimums due to COVID-19. Wellness activities centered on increased communication. All programs had begun to use videoconferencing and the majority planned to continue. Programs in states with a higher incidence of COVID-19 were more likely to report resident redeployment (48% vs 11%, p=0.002) and exposure to COVID-19 positive patients (70% vs 40%, p=0.03), and were less likely to report concerns regarding exposure (78% vs 97%, p=0.02) and personal protective equipment availability (62% vs 89%, p=0.02).As of April 1, 2020 the COVID-19 pandemic had resulted in significant changes in urology residency programs. These findings inform a rapidly changing landscape and aid in the development of best practices.

INTRODUCTION AND OBJECTIVE: In-person subinternships for visiting medical students were discouraged during the COVID-19 pandemic. The Society of Academic Urologists (SAU) endorsed virtual subinternships in urology (vSIU) and provided all institutions with a standardized vSIU Guidebook containing a structured curriculum and curated resources. We sought to evaluate the successes and limitations of the vSIU at a national level. METHODS: In December 2020, we sent anonymous surveys via email to all medical students who submitted applications to the urology residency match and to all urology residency program directors (PDs) and associate PDs on the SAU email list. Surveys evaluated goals, curriculum composition, satisfaction, and future reusability. Outcomes were evaluated on a 5-point Likert scale. RESULTS: A total of 162 students (30%) and 78 PDs (48%) completed the survey, including 76 students (47%) and 32 PDs (41%) who participated in vSIU at 29 institutions. Of these electives, 66% were 1-2 weeks in duration, 48% were full-time, and 76% utilized the SAU guidebook. Electives consisted of a wide range of curricular elements (Figure). The most important goals for both students and PDs were experiencing/demonstrating program culture and evaluating whether the program/student are a good fit (≥ 50% rated “extremely important”). These goals were achieved by > 80% of students and PDs. Overall, 79% of students and 78% of PDs rated the vSIU “excellent” or “very good.” On multivariable ordinal logistic regression, duration ≥ 3 weeks and class size ≤ 4 students were associated with higher student ratings (p

INTRODUCTION AND OBJECTIVE:We investigated the outcomes of pT0 after robot-assisted radical cystectomy (RARC).METHODS:A retrospective review of the International Robotic Cystectomy Consortium datab...

Radical cystectomy is the gold standard for nonmetastatic muscle invasive bladder cancer and for refractory nonmuscle invasive disease. Compared to open radical cystectomy, robot-assisted radical cystectomy has been shown to provide comparable early oncologic outcomes and improved perioperative outcomes. However, there is a paucity of data on long-term oncologic outcomes and concerns about a higher incidence of local recurrence after robot-assisted radical cystectomy. We report 10-year oncologic outcomes following robot-assisted radical cystectomy using a multinational database.We retrospectively reviewed the prospective International Robotic Cystectomy Consortium database. Consecutive patients who underwent robot-assisted radical cystectomy 10 years ago or earlier were included in analysis. Data were reviewed for demographics, and perioperative, pathological and oncologic outcomes. Kaplan-Meier curves were used to depict recurrence-free, disease specific and overall survival. Multivariate stepwise Cox regression models were applied to identify variables associated with recurrence-free, disease specific and overall survival.We identified 446 patients with a median age of 67 years (IQR 59-76). Of the patients 10% received neoadjuvant chemotherapy, 51% experienced any complication, 23% had high grade complications and 4% died within 3 months of robot-assisted radical cystectomy. Disease was pT3 or greater in 43% of patients and pN+ in 24% while a positive soft tissue surgical margin was observed in 7%. At a median followup of 5 years (IQR 2-10, maximum 14) local and distant recurrence had developed in 15% and 29% of patients, respectively. Ten-year recurrence-free, disease specific and overall survival rates were 59%, 65% and 35%, respectively. Patients with pT3 or greater and pN+ disease showed worse recurrence-free, disease specific and overall survival.Long-term oncologic outcomes, and recurrence rates and patterns after robot-assisted radical cystectomy seem comparable to those in open series. Advanced disease stage and positive surgical margins remain the main determinants of survival after radical cystectomy.

INTRODUCTION AND OBJECTIVE:There is limited data demonstrating the efficacy of laparoscopic training curricula, such as BLUS (Basic Laparoscopic Urologic Skills), in improving technical skills. Des...

INTRODUCTION AND OBJECTIVE:There have been concerns about higher incidence of local recurrence after robot-assisted radical cystectomy (RARC) compared to its open counterpart. We sought to report a...

INTRODUCTION AND OBJECTIVE:CSATS, a validated crowd sourced Global Evaluative Assessment of Robotic Skills scoring system, is a voluntary robotic surgery technical skills evaluation designed for su...

We evaluated contemporary practice patterns in the management of small renal masses.We identified 52,804 patients in the NCDB (National Cancer Database) who were diagnosed with a small renal mass (4 cm or less) between 2010 and 2014. Utilization trends of active surveillance, ablation and robotic, laparoscopic and open surgical techniques were compared among all comers, elderly patients 75 years old or older and individuals with competing health risks, defined as a Charlson index of 2 or greater. Multivariable logistic regression models were used to assess factors associated with robotic renal surgery and active surveillance.Surgery remained the primary treatment modality across all years studied, performed in 75.0% and 74.2% of cases in 2010 and 2014, respectively. Although increases in active surveillance from 4.8% in 2010 to 6.0% in 2014 (p0.001) and robotic renal surgery (22.1% in 2010 to 39.7% in 2014, p 0.001) were observed, the increase in the proportion of small renal masses treated with robotic partial and radical nephrectomy was greater than that of active surveillance (82.0% and 63.0%, respectively, vs 25.0%). Subgroup analyses in individuals 75 years old or older, or with a Charlson index of 2 or greater likewise revealed preferential increases in robotic surgery vs active surveillance. On multivariable analysis later year of diagnosis was associated with increased performance of robotic renal surgery compared to active surveillance (2014 vs 2010 OR 1.44, 95% CI 1.20-1.72, p0.001) and nonrobotic procedural interventions (2014 vs 2010 OR 2.59, 95% CI 2.30-2.93, p 0.001).Robotic surgical extirpation has outpaced the adoption of active surveillance of small renal masses. This raises concern that the diffusion of robotic technology propagates overtreatment, particularly among elderly and comorbid individuals.

We studied recurrence-free survival after partial vs radical nephrectomy for clinical stage T1 renal cell carcinoma in all patients and in those up staged to pathological stage T3a.We retrospectively reviewed the records of 1,250 patients who underwent partial or radical nephrectomy for clinically localized T1 renal cell carcinoma between 2006 and 2014. Recurrence-free survival was estimated using the Kaplan-Meier method and evaluated as a function of nephrectomy type with the log rank test and Cox models, adjusting for clinical, radiological and pathological characteristics.A total of 86 recurrences (7%) were observed during a median followup of 37 months. No difference in recurrence-free survival between partial and radical nephrectomy was found among all clinical stage T1 renal cell carcinomas. T3a up staging was noted in 140 patients (11%) and recurrent disease was observed in 44 (31.4%) during a median followup of 38 months. Among up staged T3a cases partial nephrectomy was associated with shorter recurrence-free survival compared to radical nephrectomy on univariable analysis (recurrence HR 2.04, 95% CI 1.12-3.68, p = 0.019) and multivariable analysis (recurrence HR 5.39, 95% CI 1.94-14.9, p = 0.001).In a subgroup of patients clinically staged T1 renal cell carcinoma will be pathologically up staged to T3a. Among these patients those who undergo partial nephrectomy appear to have inferior recurrence-free survival relative to those who undergo radical nephrectomy.

INTRODUCTION AND OBJECTIVES: In an effort to improve patient autonomy, several organizations publish online data on surgeon performance. One such organization is Pro-Publica, an independent nonprofit newsroom that publishes an online 0surgeon scorecard.0 This scorecard reports calculated death and complication rates for surgeons performing elective procedures including radical prostatectomy in Medicare patients. We wanted to understand how the general public would interpret this data and how it would impact patients’ selection of surgeon. METHODS: 265 adults at the Minnesota State Fair were asked to interpret a representative image from the Pro-Publica surgeon scorecard. Participants were told that a loved one had already scheduled cancer surgery with a surgeon they trusted. They were then shown a graphic with a dot representing the point estimate complication rate and a bar representing the 95% confidence interval (CI) of their surgeon. They were also shown a graphic with 13 other surgeons’ point estimate complication rates, all of which fell within the CI of the index surgeon’s complication rate. Another surgeon with a 0.5% lower point estimate but statistically equivalent complication rate to the first surgeon was indicated on the graphic. Participants were then asked if they would recommend switching surgeons after seeing this graphic. RESULTS: The surveyed population was educated with 89% having attended or graduated from college (n1⁄4235). Median age of participants was 50 years (range 20-74) with 68% females (n1⁄4179). Participants were from 136 different zip codes predominantly in the upper Midwest. When presented with the graphic representing two surgeons with different point estimate complication rates falling within the same confidence interval, 124 or 46.8% (95% CI 41-53) of respondents would recommend switching surgeons based on this single graphic. CONCLUSIONS: Nearly half of adults surveyed would recommend switching cancer surgeons for genitourinary malignancies based on a graphical representation of surgeons’ complication rates even though there was no statistically significant difference between the two surgeons. This suggests that simplistic displays of complicated statistical data may lead to changes in medical decision-making based on random error of measurement instead of true differences in surgeon quality.

We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery.The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications.Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p0.001), robotic approach (p0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications.Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery.

We describe our experience with laparoscopic ureteral reimplantation in 45 adults, and report success rates and complications at intermediate term followup.We performed a retrospective chart review of 45 patients who underwent laparoscopic ureteral reimplantation between 1997 and 2007. Demographics, clinicopathological parameters, perioperative course, complications and followup studies were analyzed.Elective laparoscopic ureteral reimplantation was performed in 35 female and 10 male patients with a mean followup of 24.1 months (range 1 to 76). All patients presented with distal ureteral stricture with a mean stricture length of 3 cm and a mean +/- SD preoperative serum creatinine of 0.91 +/- 0.04 mg/dl. Mean patient age was 47.8 +/- 2.2 years (range 17 to 87). Mean American Society of Anesthesiologists score was 2 (range 1 to 3). Median estimated blood loss was 150 ml. The overall success rate, defined as radiographic evidence of no residual obstruction, symptoms, renal deterioration or need for subsequent procedures, was 96%. Two patients had recurrent strictures and 1 underwent nephrectomy for flank pain and preexisting chronic pyelonephritis.According to intermediate followup data laparoscopic ureteral reimplantation can be performed with an excellent success rate and low morbidity. Our data substantiate this technique as an effective method for managing distal ureteral stricture.

We reviewed the long-term outcomes in men undergoing permanent prostate brachytherapy with a focus on those presenting before age 60 years.Between 1992 and 2005 a total of 2,119 patients with clinical stage T1-T2, N0, M0 prostate cancer treated with permanent prostate brachytherapy were included in this study. Treatment regimens consisted of permanent prostate brachytherapy with or without hormone therapy, permanent prostate brachytherapy with external beam radiotherapy, or all 3 modalities. Biochemical recurrence was defined using the Phoenix definition. Multivariate analysis was performed to determine if age and/or other clinicopathological features were associated with disease progression. The Kaplan-Meier method was used to calculate rates of freedom from progression with the log rank test to compare patients younger than 60 vs 60 years or older.Median followup was 56.1 months. In the study population 237 patients were younger than 60 years at diagnosis (11%). The 5 and 10-year freedom from progression rates were 90.1% and 85.6%, respectively, for the entire population. Multivariate analysis demonstrated that prostate specific antigen (p0.01), biopsy Gleason score (p0.0001) and year of treatment (p0.001) were associated with freedom from progression while age (p = 0.95) and clinical stage (p = 0.11) were not. There was no significant difference in freedom from progression between men younger than 60, or 60 years or older (log rank p = 0.46). In the younger cohort the 10-year freedom from progression for patients presenting with low, intermediate and high risk disease was 91.3%, 80.0% and 70.2% compared to 91.8%, 83.4% and 72.1%, respectively, for men 60 years or older.Our long-term results confirm favorable outcomes after permanent prostate brachytherapy in men younger than 60 years. Outcomes are impacted by disease related risk factors but not by age or clinical stage. Definitive treatment options for younger men with clinically localized prostate cancer should include permanent prostate brachytherapy.

There are limited data on the indications for open conversion during laparoscopic surgery. The frequency of conversion for various procedures is poorly quantified and the degree to which this changes with time is not well understood. Risk factors for conversion are not defined. We addressed these issues in a large series of laparoscopic operations.We reviewed our database of 2,128 laparoscopic operations performed between 1993 and 2005, including radical nephrectomy in 549 patients, simple nephrectomy in 186, partial nephrectomy in 347, donor nephrectomy in 553, pyeloplasty in 301, nephroureterectomy in 106 and retroperitoneal lymph node dissection in 86. Open conversions were identified and the frequency of conversion for the total cohort and specific procedures was determined. Trends in conversion with time were assessed and indications analyzed. Clinicopathological features between patients requiring conversion and those who did not were compared.We identified 68 patients (3.3%) who underwent conversion to open surgery (group 1) and 2,011 (96.7%) who did not (group 2). The frequency of conversion was greatest during nephroureterectomy (8.49%), followed by simple nephrectomy (5.91%), retroperitoneal lymph node dissection (4.65%), partial nephrectomy (4.32%), radical nephrectomy (2.91%), donor nephrectomy (2.53%) and pyeloplasty (0.33%). The absolute number of conversions and conversions/cases performed per year decreased significantly with time, reaching a nadir of less than 1% per year. Conversion was inversely related to case volume and cumulative experience. Indications included vascular injury in 38.5% of cases, concern with margins in 13.5%, bowel injury in 13.5%, failure to progress in 11.5%, adhesions in 9.6%, diaphragmatic injury in 1.9% and other in 11.5%. The distribution of indications remained similar with time. There were no differences in patient age, gender, surgical history, American Society of Anesthesiologists score or tumor stage between groups 1 and 2. In groups 1 and 2 mean operative time was 304 vs 219 minutes and estimated blood loss was 904 vs 255 cc (each p0.0001).The rate of conversion during laparoscopic surgery is not uniform across procedures and it is important for patient counseling. The most common indication for conversion is vascular injury. Importantly the frequency of conversion is dynamic and likely related to case volume and cumulative experience.

INTRODUCTION AND OBJECTIVES: Robotic-assisted simple prostatectomy (RASP) has been demonstrated to be an acceptable alternative to open simple prostatectomy (OSP) for the treatment of high-volume symptomatic BPH. We performed a matched analysis comparing clinical and perioperative outcomes following RASP and OSP at our institution. METHODS: We identified 15 consecutive patients who underwent RASP between 2013 and 2014. They were 1:1 matched to patients from our OSP database based on preoperative prostate size ( 10 cc) by CT or ultrasound imaging, age ( 10 years), BMI ( 5), and ASA score ( 1). Perioperative and clinical data were examined. Analyses for comparison and statistical significance were performed using the paired two-tailed student’s t-test. RESULTS: Patients in the OSP group were found to be of comparable age (74.1 and 68.8, p 1⁄4 0.11), BMI (26.3 and 28.5, p 1⁄4 0.16), and ASA score (2.6 and 2.6, p 1⁄4 1.0) to the RASP group. OSP prostate size was 158.6 cc (156.1 cc in RASP group). The mean volume of tissue resected was similar between the OSP and RASP groups (112.6 cc and 104.7 cc respectively, p 1⁄4 0.42). Length of stay was significantly shorter in the RASP group (2.4 vs 6 days, p

INTRODUCTION AND OBJECTIVES: Adult patients with myelomeningocele (MMC) and the associated neurogenic bladder require consistent, lifelong vigilance. Preventing these complications may be possible if adequate surveillance can be implemented for these patients. Our objectives are to evaluate the adequacy of urologic surveillance in this population and to outline the prevalence and risk factors for medical complications. METHODS: We performed a retrospective cohort study using a 5% sample of Medicare administrative data from 2007 2010. We used the Paralyzed Veterans of America screening guideline to define the minimum adequacy of surveillance: serum creatinine, upper urinary tract imaging and a urologist visit within a 2 year period. Neurogenic bladder associated complications and diagnosis of MMC were collected using ICD 9 codes. Complications were graded based on their clinical implications. We completed a multivariate analysis to identify predictors of complications based on severity. We included the following variables: age, gender, race, travel distance to referral center, and geographic location of residence. RESULTS: 825 MMC patients were included in our study and were a predominantly Caucasian (85.1%) female population (61.3%) with a mean age of 51.2 þ/ 17.2 years. Most patients (61.3%) received some form of neurogenic bladder surveillance, although only 33% of the patients met the minimum acceptable criteria for adequacy. A urologist visit within two years took place for 44% of the patient population. Most complications observed in the patient sample were mild complications, which occurred in 27.6% of patients. Moderate and severe complications were observed in 17.0% and 6.6% of patients, respectively. The most common complications were acute or recurrent cystitis (16.4%), pressure ulcers (7.1%), chronic kidney disease (4.4%), and kidney infection (3.7%). Multivariate analysis showed that the risk factors for increased complications included younger patient age, male gender and better adequacy of neurogenic bladder surveillance. CONCLUSIONS: This retrospective sample of patients highlights the opportunity for improvement in surveillance in this susceptible population. The select minority of patients who received adequate observation was diagnosed with a larger number of complications. Disease ascertainment may be better in the adequately screened MMC population. This emphasizes a need for a close watch on this high risk patient population.

We determined the frequency of tumor multifocality in patients with renal cortical tumors, characterized clinical and pathological features associated with multifocality and evaluated its effect on patient survival.Between July 1989 and July 2002, 1,071 radical nephrectomies were performed at our institution. Specimens were examined grossly and microscopically for multifocal tumors. Preoperative imaging was reviewed to determine whether multifocality was suspected prior to operation. Multivariate analysis was performed to identify clinical and pathological factors associated with multifocality.Of 1,071 radical nephrectomy specimens 57 (5.3%) had pathological evidence of tumor multifocality. Bilateral synchronous renal cortical tumors were present in 6 of the 57 multifocal cases (11%). A total of 19 cases (33%) had evidence of multifocality on preoperative imaging and, therefore, occult multifocality undetected on preoperative imaging was present in 3.5% of radical nephrectomies (38 of 1,071). Primary tumors in the multifocal group were most commonly conventional clear cell carcinoma, followed by papillary carcinoma. Of multifocal cases 74% had the same histological subtype in all tumors. Multivariate analysis demonstrated that bilaterality, papillary subtype, advanced tumor stage and lymph node metastasis were associated with multifocality. At a median follow up of 40.5 months overall survival, disease-free survival, and disease-free probability were not significantly different between the multifocal and unifocal groups.We report a 5.3% frequency of multifocal renal cortical tumors and a 3.5% frequency of clinically unsuspected multifocal tumors. Multifocality had no apparent effect on recurrence or survival in patients who underwent radical nephrectomy.

Matthias Saar*, Homburg Saar, Germany; Syed Johar Raza, John Binkowski, Buffalo, NY; Lee Richstone, New York, NY; Andrew Wagner, Boston, MA; Timothy Wilson, Duarte, CA; Joan Palou Redorta, Barcelona, Spain; Prokar Dasgupta, London, United Kingdom; James Peabody, Detroit, MI; Peter Wiklund, Stockholm, Sweden; Franco Gaboardi, Milan, Italy; Alex Mottrie, Aalast, Belgium; Stephan Siemer, Homburg Saar, Germany; Raj Pruthi, Chapel Hill, NC; Alon Weizer, Ann Arbor, MI; Francis Schanne, Newark, DE; Khurshid Guru, East Amherst, NY; Koon-ho Rha, Seoul, Korea, Republic of; Ashok Hemal, Winston-Salem, NC; Douglas Scherr, New York, NY; Michael Stockle, Homburg Saar, Germany

during the enucleation. The mean blood loss was 130.2 iA 56.1 ml (laparoscopic 113.9 iA 44.1 ml vs open 154.2 iA 64.2 ml) and mean operation time was 134.2 iA 32.0 min (laparoscopic 126.6iA27.1 min vs open 145.5iA35.9 min). Overall 8 complications (17.0%) occurred including 4 postoperative fevers (Clavien-Grade II), 1 bleeding need transfusion (Clavien-Grade II) and 3 prolonged urinary leakages (Clavien-Grade III). PADUA score was associated with prolonged urinary leakage (p 0.01) but not overall complications. No patient had positive surgical margins. Glomerular filtration rate differed before and 12 months after surgery with 2.0 mL/min/1.73 m2 decline at the first year after the surgery. One patient with a 5.1cm renal tumor had recurrence near the renal sinus near the ablation zone 9 month after surgery and received laparoscopic radical nephrectomy. CONCLUSIONS: Zero-ischemia, RFA assisted TE is a safe and effective nephron sparing treatment for T1b renal cell carcinoma that may provides excellent oncological and functional outcomes.